US20070118023A1 - Devices and methods for percutaneous tissue retraction and surgery - Google Patents

Abstract

Methods and devices for performing percutaneous surgery in a patient are provided. A retractor includes a working channel formed by a first portion coupled to a second portion. The first and second portions are movable relative to one another from an unexpanded configuration to an expanded configuration to increase the size of the working channel along the length of the working channel while minimizing trauma to skin and tissue.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application is a divisional application of U.S. patent application Ser. No. 10/117,440 filed on Apr. 5, 2002, which is incorporated herein by reference in its entirety.
BACKGROUND
• The present invention relates to devices, instruments and methods for performing percutaneous surgeries.
• Traditional surgical procedures for pathologies located deep within the body can cause significant trauma to the intervening tissues. These open procedures often require a long incision, extensive muscle stripping, prolonged retraction of tissues, denervation and devascularization of tissue. These surgeries can require operating room time of several hours and several weeks of post-operative recovery time due to the use of general anesthesia and the destruction of tissue during the surgical procedure. In some cases, these invasive procedures lead to permanent scarring and pain that can be more severe than the pain leading to the surgical intervention.
• The development of percutaneous procedures has yielded a major improvement in reducing recovery time and post-operative pain because minimal muscle and tissue dissection is required and the procedures can be performed under local anesthesia. For example, minimally invasive surgical techniques are desirable for spinal and neurosurgical applications because of the need for access to locations deep within the body and the danger of damage to vital intervening tissues. While developments in minimally invasive surgery are steps in the right direction, there remains a need for further development in minimally invasive surgical devices and techniques.
SUMMARY
• The present invention is directed to methods and devices for performing surgery in a patient. One specific application concerns devices, instruments and techniques for percutaneous, minimally invasive spinal surgery. A further specific application includes percutaneous tissue retraction to provide access to the surgical location in the patient. Another specific application includes surgery performed through the percutaneously retracted tissue under direct vision at any location in the body. Also contemplated are surgical methods and techniques employing the instruments and devices described herein.
DESCRIPTION OF THE FIGURES
• FIG. 1 is a perspective view looking toward one side of a retractor in an unexpanded configuration.
• FIG. 2 is a perspective view looking toward the bottom of the retractor ofFIG. 1.
• FIG. 3 is a perspective looking toward the other side of the retractor ofFIG. 1 with the retractor in an expanded configuration.
• FIG. 4 is a perspective view looking toward the bottom of the expanded retractor ofFIG. 3.
• FIG. 5 is a side view of the retractor shown inFIG. 1 inserted through an incision in a patient with the retractor in an unexpanded configuration.
• FIG. 6 is the retractor ofFIG. 5 in an expanded configuration and with viewing instruments diagrammatically shown.
• FIG. 7 is a perspective view looking toward the bottom of the expanded retractor ofFIG. 3.
• FIG. 8 is a top plan view of the expanded retractor ofFIG. 3.
• FIG. 9 is a perspective view of the upper portion of the unexpanded retractor ofFIG. 1.
• FIG. 10 is a perspective view of the upper portion of the expanded retractor ofFIG. 3.
• FIG. 11 is a perspective view of the upper portion of the unexpanded retractor ofFIG. 1 with an expansion instrument positioned adjacent thereto.
• FIG. 12 is a perspective view of the retractor ofFIG. 3 with the expansion instrument ofFIG. 11 positioned therein to move the retractor to its expanded configuration.
• FIGS. 13a-13dcillustrate another embodiment expansion instrument having an adjustable foot.
• FIGS. 14a-14cillustrate another embodiment expandable retractor and a coupling member comprising a portion thereof
• FIGS. 15a-15cillustrate the proximal end of yet another embodiment expandable retractor.
• FIGS. 16a-16billustrate another embodiment expandable retractor.
DESCRIPTION OF THE ILLUSTRATED EMBODIMENTS
• For the purposes of promoting an understanding of the principles of the invention, reference will now be made to the embodiments illustrated in the drawings and specific language will be used to describe the same. It will nevertheless be understood that no limitation of the scope of the invention is thereby intended. Any such alterations and further modifications in the illustrated devices and described methods, and such further applications of the principles of the invention as illustrated herein are contemplated as would normally occur to one skilled in the art to which the invention relates.
• The present invention provides instruments and methods for performing percutaneous surgery, including spinal surgeries that include one or more techniques such as laminotomy, laminectomy, foramenotomy, facetectomy, discectomy, interbody fusion, spinal nucleus or disc replacement, and implant insertion, for example. The surgery is performed through a working channel or passageway provided by a retractor. Viewing of the surgical site at the working end of the retractor can be accomplished with optics mounted on the retractor, positioned over the retractor, and/or through a viewing system such as lateral fluoroscopy. The retractor is expandable in situ to increase the size of the working channel to facilitate access to the working space at the distal end of the retractor while minimizing trauma to tissue surrounding the retractor. The retractor can be used with any surgical approach to the spine, including anterior, posterior, posterior mid-line, lateral, postero-lateral, and/or antero-lateral approaches, and in other regions besides the spine.
• InFIGS. 1-2 there is illustrated aretractor20 that includes afirst portion22 coupled to asecond portion42.First portion22 has adistal end24 and an oppositeproximal end26.Second portion42 has adistal end44 and an oppositeproximal end46. In the illustrated embodiment,first portion22 is pivotally coupled tosecond portion42 atproximal ends26,46. A workingchannel50 is formed byfirst portion22 andsecond portion42. Workingchannel50 extends between and opens atdistal ends24,44 andproximal ends26,46.Retractor20 is movable to an expanded configuration, as shown inFIGS. 3-4, by pivotingfirst portion22 andsecond portion42 relative to one another aboutproximal ends26,46. Other coupling arrangements are also contemplated that allow first portion andsecond portion42 to be moved away from one another to expandretractor20 and increase the size of workingchannel50 between its distal and proximal ends.
• Retractor20 is insertable through skin and tissue of a patient to provide workingchannel50 to the surgical site. It is contemplated thatretractor20 is inserted through the skin and tissue in an unexpanded configuration, such as shown inFIGS. 1-2. After insertion into the patient,retractor20 is expanded through the skin and tissue to an expanded configuration that increases the size of workingchannel50 fromproximal ends26,46 todistal ends24,44.
• First portion22 includes asemi-cylindrical body23 extending betweendistal end24 andproximal end26. Acollar28 extends aboutproximal end26, and forms alip28aextending about the outer surface ofbody23.Second portion42 includes asemi-cylindrical body43 extending betweendistal end44 andproximal end46. Acollar48 extends aboutproximal end46 ofsecond portion42, and defines alip48aextending about the outer surface ofbody43. Afirst coupling member30apivotally couples a first side offirst portion22 tosecond portion42 at theirproximal ends26,46. Asecond coupling member30boppositefirst coupling member30apivotally couples the other side offirst portion22 tosecond portion42 at theirproximal ends26,46 along another side ofretractor20.
• In the illustrated embodiment, first andsecond coupling members30a,30bare pins that extend through aligned holes or passageways provided throughcollars28,48 to pivotally couplefirst portion22 tosecond portion42. Other coupling arrangements are also contemplated atproximal ends26,46 of first andsecond portions22,42. For example,proximal end26 offirst portion22 may be hingedly attached toproximal end46 ofsecond portion42 with one or more hinges at each side ofretractor20. In another embodiment, at least the proximal ends offirst portion22 andsecond portion42 are formed of a single piece of material and a resilient hinge couplesfirst portion22 tosecond portion42 at theirproximal ends26,46. Other embodiments contemplate a slotted arrangement extending around the proximal end of one of the retractor portions and one or more pins from the other retractor portion received in the slotted arrangement.
• Abracket40 extends from and is integrally formed with or attached tocollar48 ofsecond portion42.Bracket40 can also be provided oncollar28 in lieu of or in addition tobracket40 oncollar48.Bracket40 extends away from workingchannel50 and is connectable to one end of a flexible or articulatable arm41 (FIG. 6.) The opposite end of arm41 (not shown) can be mounted on the surgical table or other support device.Arm41 supports retractor20 in the patient yet allows percutaneous manipulation and re-positioning ofretractor20.
• Body23 offirst portion22 extends around at least a portion ofbody43 ofsecond portion42.Body23 has a perimeter length alongdistal end24 which is greater than the perimeter length ofbody23 atproximal end26.Body43 ofsecond portion42 includes a perimeter length alongdistal end44 which is the same or can be about the same as the perimeter length ofbody43 adjacentproximal end46.Body23 offirst portion22 can be flexible enough to extend aroundsecond portion42 in form fitting relationship whenretractor20 is the unexpanded configuration ofFIGS. 1 and 2 to minimize the profile ofretractor20.Body23 flexes outwardly and rides along the outer surface ofbody43 ofsecond portion42 asfirst portion22 andsecond portion42 are pivoted relative to one another to the expanded configuration ofretractor20.
• In one specific embodiment,first portion22 andsecond portion42 are each made from surgical grade stainless steel. Other materials are also contemplated forbodies23,43, including, for example, plastics and metals and metal alloys, such as, for example, spring steel, shape memory metals and alloys, and aluminum. It is contemplated thatbody23 can be provided with a cross-sectional thickness t1 that provides the desired flexibility, yet is sufficiently rigid to maintain retraction of the skin and tissue.Body43 ofsecond portion42 can be provided with a thickness t2 that can be the same or greater than thickness t1 offirst portion22. The reduced thickness ofbody23 provides it greater flexibility to flex inwardly and outwardly expand aroundbody43 ofsecond portion42. Thickness t2 providessecond portion43 greater rigidity to resist bending or bowing under the forces exerted on it bybody23 during and after movement ofretractor20 to its expanded configuration.
• In the unexpanded configuration, workingchannel50 has a generally circular cross-section alongretractor20, as best shown inFIG. 2. Workingchannel50 has a first width D1 between the opposite edges ofsecond portion42 positioned infirst portion22. A second width D2 is defined between the mid-portions offirst body23 andsecond body43 in the direction of expansion offirst portion22 relative tosecond portion42. In the illustrated embodiment, first and second widths D1 and D2 are substantially the same since unexpanded workingchannel50 has a generally circular cross-section. In the expanded configuration, as shown inFIG. 4, the portion of the expanded workingchannel50 extending along the opposite edges ofsecond body43 maintains first width D1. However,first body23 is flexed outwardly relative tosecond body43, and defines a third width D3 between the sides offirst body23 that is greater than first width D1. In the expanded configuration of workingchannel50,first body23 andsecond body43 define a fourth width D4 in the direction of expansion offirst portion22 relative tosecond portion42 that is greater than second width D2. It is further contemplated that width D4 can be greater than widths D1 and D3.
• Various configurations for workingchannel50 are contemplated. In the unexpanded configuration, workingchannel50 can have a cylindrical shape with, for example, a circular, oval, elliptical, or polygonal cross-section. In the expanded configuration, workingchannel50 can have a frusto-conical shape with, for example a cross-section that is figure-eight or snowman shaped, oval, elliptical, circular or polygonal. In at least the direction of expansion, the size of the cross-section of workingchannel50 decreases from distal end to the proximal end ofretractor20.
• In one specific application for spinal surgery, it is contemplated that, after insertion ofretractor20,first portion22 andsecond portion42 are expanded predominantly in one direction to retract muscle and tissue along pathway P. For example,retractor20 can be primarily or predominantly expandable in the direction of the spinal column axis. Since the muscle tissue adjacent the spine has a fiber orientation that extends generally in the direction of the spinal column axis, the expansion ofretractor20 separates the muscle tissue along the fibers, thus minimizing their separation and the resultant tearing and trauma to the muscle tissue is minimized. It is also contemplated in othertechniques employing retractor20 that workingchannel50 expands primarily in a direction other than along the spinal column axis or in areas other than spine. Embodiments ofretractor20 are also contemplated in which workingchannel50 is circular or polygonal in cross-section and expands substantially the same amount in all directions.
• Referring now toFIGS. 5-6, positioning ofretractor20 through the skin S and tissue T of the patient will be described. An incision is made in skin S adjacent the location of a patient's anatomy to be accessed. For example, in spinal surgery, the incision can be made at a vertebral level at a location that provides access to the disc space between adjacent vertebrae or to one or more vertebra through a desired approach. Prior to insertion ofretractor20, skin S and tissue T can be sequentially dilated via guidewires and/or one or more dilators of increasing size to form a pathway P through skin S and tissue T to the surgical site in the patient. In such procedures,retractor20 is positioned over the last inserted dilator in pathway P forretractor20. Workingchannel50 throughretractor20 provides access to a working space WS at the distal end ofretractor20 when the guidewires and dilators, if used, are removed therefrom.
• For the entire surgery or for certain procedures, it may be desired by the surgeon to increase the size of workingchannel50 to facilitate access working space WS below the distal end ofretractor20, or to even provide a greater working space WS.Retractor20 can be pivoted from its unexpanded, insertion configuration to an expanded configuration as shown inFIG. 6. In the expanded configuration,first portion22 andsecond portion42 are pivoted away from one another about first andsecond coupling members30a,30bat proximal ends26,46. In the expanded configuration, pathway P′ through skin S and tissue T is formed byfirst portion22 andsecond portion42. The size of working space WS can be increased while minimizing trauma to the tissue and skin along pathway P.
• Workingchannel50 has a tapered configuration that reduces in size from the distal end ofretractor20 adjacent working space WS through skin S to the proximal end ofretractor20. The tapered working channel provides the surgeon greater access and increased visualization of working space WS. The tapered workingchannel50 also allows greater angulation of instruments placed through workingchannel50, more selection in positioning of instruments within workingchannel50, and the ability to position instruments adjacent the inner wall surfaces of the expanded first andsecond portions22,42, increasing the room available at working space WS for multiple instruments.
• Viewing instruments can be positioned in or adjacent to workingchannel50 to facilitate surgeon viewing of working space WS and the operative site. For example, anendoscopic viewing element90 can be mounted on the proximal end ofretractor20 such that itsscope portion92 extends along workingchannel50. Amicroscopic viewing element95 can also be positioned over the proximal end ofretractor20 for viewing working space WS and the surgical site. Other imaging techniques, such as lateral fluoroscopy, can be used alone or in combination with the endoscopic and microscopic viewing elements. Further examples of such viewing instruments and mounting or orienting the same relative to retractor20 are provided in U.S. patent application Ser. No. 09/815,963 filed on Mar. 23, 2001, which is hereby incorporated herein by reference in its entirety. It is further contemplated that other instruments can be mounted on the proximal end ofretractor20, such as nerve root retractors, tissue retractors, irrigation and/or aspiration instruments, illumination instruments and the like for use in surgical procedures throughretractor20 in the working space.
• Referring now toFIG. 7, further details regarding the engagement offirst portion22 andsecond portion42 whenretractor20 is in the expanded configuration will be provided.First body23 offirst portion22 includes afirst edge32aextending betweendistal end24 andproximal end26.First body23 offirst portion22 includes an oppositesecond edge32bextending betweendistal end24 andproximal end26.Second portion42 includes afirst edge51 a extending along one side ofsecond body43 and an oppositesecond edge51 b extending along the opposite side ofsecond body43. First edge51aincludes a groovedportion54aextending fromdistal end44 along at least a portion of the length offirst edge51a. Anengagement surface52aextends along groovedportion54a. Similarly,second edge51bincludes groovedportion54bextending fromdistal end44 along at least a portion of the length ofsecond edge51b.Anengagement surface52bextends along groovedportion54b.
• Withretractor20 in its expanded configuration,first edge51aofsecond body43 is is adjacentfirst edge32aoffirst body23, andsecond edge51bofbody43 is adjacentsecond edge32boffirst body23. First edge32aresides at least partially ingrooved portion54a, andsecond edge32bresides at least partially ingrooved portion52b. First edge32acontacts engagement surface52aalong groovedportion54ato maintainretractor20 in its expanded configuration. Similarly,second edge32bcontacts engagement surface52bingrooved portion54bto maintainretractor20 in its expanded configuration. The flexiblesecond portion22 tends to return toward its unexpanded configuration, thus first andsecond edges32a,32bfrictionally engage the engagement surfaces extending along each of thegrooved portions54a,54b. This locksfirst portion22 with respect tosecond portion42 in the expanded configuration, resisting collapse of the working channel by pressure of the surrounding tissue on first andsecond portions22,42 and facilitating manipulation ofretractor20 in the tissue without collapse of the working channel.
• Other means for locking first andsecond portion22,42 in the expanded configuration are also contemplated. For example,second portion42 can be provided with a ridge or protrusion at each of its opposite edges, andfirst portion44 can engage the ridge or protrusion.
• By maintaining a closed configuration for the working channel betweenfirst portion22 andsecond portion42 in the expanded configuration, migration of tissue into workingchannel50 is prevented by the walls of first andsecond portions22,42. Other embodiments contemplate that workingchannel50 is not completely enclosed.
• Referring now toFIGS. 8-10, further details regarding proximal ends26,46 of first andsecond portions22,42 will be described.Collar28 includes arecess33aformed adjacentfirst edge32aon one side offirst portion22, and asecond recess33boppositefirst recess33aon the other side offirst portion22.Recess33aincludes anengagement surface35aalong an inner side thereof, andsecond recess33bincludes anengagement surface35bextending along an inner side thereof. Afirst extension34aextends along the outside offirst recess33a, and asecond recess34bextends along the outside ofsecond recess33b.First extension34aandsecond extension34bextend beyond the adjacentfirst edge32aandsecond edge32b, respectively, ofbody23 offirst portion22.
• Second portion42 includes afirst recess55aalong one side ofsecond portion42, and asecond recess55balong another side ofsecond portion42.First recess55aincludes anengagement surface56a, andsecond recess55bincludes anengagement surface56b. Afirst extension58aextends along the inner side offirst recess55a, and asecond extension58bextends along the inner side ofsecond recess55b.First extension58aincludes anengagement surface59a,andsecond extension55balso includes a similarly situated engagement surface.First extension58aresides withinfirst recess33aadjacentfirst extension34aoffirst portion22, andsecond extension58bresides withinsecond recess33badjacentsecond extension34boffirst portion22.First coupling member30aincludes a pin extending throughpassage31aoffirst extension34aoffirst portion22 and pivotally couplesfirst extension58aofsecond portion42 thereto.Second coupling member30bincludes a pin extending throughpassage31bofsecond extension34boffirst portion22 and pivotally couplessecond extension58bofsecond portion42 thereto.
• Withretractor20 in its unexpanded configuration as shown inFIG. 9, a gap is formed between engagement surfaces35a,35boffirst portion22 and engagement surfaces59a,59aofextensions58a,58bofsecond portion42. Asretractor20 is moved to its expanded configuration as shown inFIG. 10, engagement surfaces59a,59acontact engagement surfaces35a,35boffirst portion22. Also, engagement surfaces37a,37bofextensions34a,34boffirst portion22 contact engagement surfaces56a,56bofsecond portion42. The contact between the engagement surfaces of the recesses and extensions limit the pivotal movement offirst portion22 relative tosecond portion42.First portion22 can include arelieved portion39abelowfirst engagement surface59aand a similar relief undersecond engagement surface35b. The reliefs allow some flexing of engagement surfaces35a,35bto ensureengagement surfaces59a,59bofextensions58a,58bfully seat onengagement surfaces35a,35b.
• Referring now toFIGS. 11-12 there is shownretractor20 with anexpansion instrument60.Expansion instrument60 includes afirst handle62 pivotally coupled to asecond handle64 withpin66. Aleaf spring68 can extend betweenfirst handle62 andsecond handle64 to bias handles62,64 in a closed position as shown inFIG. 11. Extending distally from the pivotal connection offirst handle62 andsecond handle64 are firstdistal portion70 and seconddistal portion72, respectively.Distal portion70 includes afoot74 at a distal end thereof, anddistal portion72 includes afoot76 at a distal end thereof.Feet74,76 extend towardfirst portion22 andsecond portion42, respectively whenexpansion instrument60 is inserted in workingchannel50 ofretractor20.
• Expansion instrument60 includes afirst arm78aand asecond arm78babovepin66.First arm78ais pivotally coupled to first andsecond handles62,64 viacoupler84a, andsecond arm78bis pivotally coupled to first andsecond handles62,64 viacoupler84b. First andsecond arms78a,78bextend transversely to the orientation offeet74,76.First arm78aincludes anengagement member80ahaving areceptacle82apositionable over the head offirst coupling member30a.Second arm78bincludes anengagement member80bhaving a receptacle positionable over the head ofsecond coupling member30b.
• As shown inFIG. 12,expansion instrument60 is mountable onretractor20 by pivotingfirst arm78aso thatfirst coupling member30ais captured inreceptacle82aofengagement member80a, andsecond coupling member30bis captured in receptacle82bofengagement member80b. The engagement ofexpansion instrument60 toretractor20 ensures thatexpansion instrument60 is not inserted too far into workingchannel50 before and during insertion, and allows the application a steady and uniform expansion force withoutexpansion instrument60 slipping relative toretractor20. Withexpansion instrument60 mounted onretractor20, handles62,64 are pressed toward one another in order to movefeet74,76 away from one another transverse to the pivot axis offirst portion22,second portion42 and into contact with adjacentfirst portion22 andsecond portion42.Feet74,76 apply a force onfirst portion22 andsecond portion42 to pivot first andsecond portions22,42 about their proximal ends to moveretractor20 to its expanded configuration.Retractor20 can be locked in the expanded configuration by engagement ofedges32a,32boffirst portion22 with the respective engagement surfaces ofsecond portion42.
• To collapseretractor20 to its unexpanded configuration,expansion instrument60 is rotated 90 degrees so thefeet74,76 can apply an expansion force tofirst portion22 in the direction of the pivot axis offirst portion22 andsecond portion42. The expansion offirst portion22 in this direction disengages or unlocksedges32a,32bfromengagement surfaces52a,52bofsecond portion42 and allowsfirst portion22 andsecond portion42 to pivot relative to one another tounexpand retractor20.Retractor20 can then be withdrawn from the tissue in its unexpanded condition, minimizing pressure on the adjacent tissue asretractor20 is withdrawn.
• Referring now toFIGS. 13a-13d, there is shown anotherembodiment expansion instrument60′. Except as otherwise provided,expansion instrument60′ can be similar toexpansion instrument60 discussed above, and like elements betweenexpansion instruments60 and60′ are designated with the same reference numeral.Expansion instrument60′ includes amovable foot74′ coupled todistal portion70′. In the illustrated embodiment, foot74′ is rotatable aboutpin75′ relative todistal portion70′ in order to position selected ones of the retractor portion contact surfaces74a′,74b′ or74c′ adjacent one of theretractor portions22,42.
• The contact surfaces74a′,74b′ and74c′ are located at differing distances frompin75′ to allow the surgeon to select the desired amount of expansion forretractor20.Foot74′ is rotated aboutpin75′ to select the desired contact surface by orienting the desired contact surface away fromcontact surface76aoffoot76. For example, as shown inFIG. 13a,contact surface74a′ is selected to provide minimum expansion since it is located closest to pin75′. InFIG. 13bcontact surface74b′ is selected to provide maximum expansion since it is located furthest away frompin75′. InFIG. 13ccontact surface74c′ is selected to provide intermediate expansion since it has a distance frompin75′ that is between the distances ofcontact surface74a′ andcontact surface74b′.FIG. 13dshowsexpansion instrument60′ mounted onretractor20 withcontact surface74c′ offoot74 in contact withsecond portion42 and contact surface76aoffoot76 in contact withfirst portion22 ofretractor20.
• It is further contemplated that the amount of expansion provided by each of the contact surfaces74a′,74b′ and74c′ can correspond to a particular retractor length. For example, withexpansion instrument60′ mounted on the retractor, the depth whichexpansion instrument60′ extends into the retractor is the same no matter the length of the retractor. Thus, to provide the same size opening at the distal end of the retractor, the first and second portions of a shorter retractor will be separated a greater amount at the depth offeet74′,76 than will a longer retractor. Accordingly,contact surface74a′ can be selected for a longer length retractor,contact surface74b′ can be selected for a shorter length retractor, andcontact surface74c′ can be selected for an intermediate length retractor.
• Of course,expansion instruments60,60′ can be oriented so thatfeet74,74′ contactfirst portion22 andfoot76 contactssecond portion42. It is further contemplated thatexpansion instruments60,60′ can be provided so that they are not mountable on the retractor, but rather are held in position at the desired depth in the retractor for expansion of the retractor.
• It is contemplated that for spinal surgeryvarious retractors20 can be provided in a kit with lengths ranging from 20 millimeters to 100 millimeters in increments of 10 or 20 millimeters. It is further contemplated thatretractor20 can be provided in a kit with various diameters, such as 14, 16, 18, 20, 21 or 25 millimeters in its unexpanded configuration. It should be understood, however, that the present invention contemplates thatretractor20 can have other lengths and diameters and can be provided in a kit with different increments. The appropriate length forretractor20 will depend on the depth of the desired surgical location below the skin S of the patient, the anatomical location of the surgery, and the patient's anatomy. These factors in retractor selection can be evaluated through pre-operative planning prior to surgery by x-rays or other known imaging technique, and can be adjusted during the surgical procedure if necessary since retractors of differing lengths and diameters can be made available.
• InFIGS. 14a-14b, there is shown another embodimentexpandable retractor220. InFIG. 14a,retractor220 is in its unexpanded configuration and inFIG. 14bretractor220 is in its expanded configuration.Retractor220 is similar in many respects to retractor20 discussed above.Retractor220 includes afirst portion222 having adistal end224, aproximal end226, and acollar228 atproximal end226.Retractor220 further includes asecond portion242 having adistal end244, aproximal end246, and acollar248 atproximal end246.First coupling member230aandsecond coupling member230bpivotally couplefirst portion222 tosecond portion242. Afirst lever arm232ais connected with and extends fromfirst coupling member230aaround collar248, and asecond lever arm232bis connected with and extends fromsecond coupling member230baroundcollar248.
• In the unexpanded configuration, leverarms232a,232bareadjacent collar248, andcoupling members230a,230bproject outwardly fromcollar228 as shown inFIG. 14a. Couplingmembers230a,230b, as shown inFIG. 13c, have a first keyedportion237 configured to engage slottedhole234 ofcollar248. Thecylindrical portions239 ofcoupling members230a,230brotatably reside in the slotted hole (not shown) extending throughcollar228 offirst portion222. This allowsfirst portion222 to be pivoted relative tosecond portion242 about couplingmembers230a,230b.
• Whenfirst portion222 is pivoted relative tosecond portion242 to the expanded configuration, the slotted portions of slottedhole234 and the slotted hole throughcollar228 are aligned. Couplingmembers230a,230bcan be pressed inwardly so that a second keyedportion235 ofcoupling members230a,230bengages the slotted hole formed throughcollar228, while the first keyedportion237 remains engaged in slottedhole234 ofcollar248, thus fixingfirst portion222 relative tosecond portion242. Leverarms232a,232bextend away fromcollar248 whenfirst portion222 is locked relative tosecond portion242. To move retractor220 to the unexpanded configuration, leverarms232a,232bare pressed towardcollar248 to movecoupling members230a,230band their second keyedportions235 out of engagement with the slotted holes incollar228 offirst portion222.First portion222 can then pivot towardsecond portion242 to collapseretractor220 for withdrawal from the patient.
• In this embodiment, rather than providing an engagement surface along the opposite edges ofsecond portion242, the keyed engagement ofcoupling members230a,230band first andsecond portions222,242 locks retractor220 in its expanded configuration. However, the provision of a grooved portion and engagement surface is not precluded.
• Other means for maintaining first and second portions of the retractor in an expanded configuration are also contemplated. For example, inFIGS. 15a-15canother embodimentexpandable retractor120 is shown with a ratchet and pawl type mechanism at the proximal ends offirst portion122 andsecond portion142. In this embodiment, rather than providing a grooved portion and engagement surface along the opposite edges ofsecond portion142, the ratchet and pawl mechanism maintainsretractor120 in its expanded configuration. However, the provision of a grooved portion and engagement surface is not precluded.
• First portion122 includes acollar128 at its proximal end.Collar128 includes anextension134 extending from each side thereof, it being understood that only one side is shown inFIGS. 15a-15c. Similarly,second portion142 includes anextension158 extending from each side thereof that is positionable alongsideextension134 offirst portion122, it being understood that only one side is shown inFIGS. 15a-15c. Apin130pivotally couples extensions134,158 to one another.Extension134 includes a number ofteeth137 formed at the end thereof that are engageable withends156 ofpawls157 extending aroundcollar148.Pawls157 are biased into engagement withteeth137 and moveable relative tocollar148 for disengagement ofends156 withteeth137.
• When in the unexpanded configuration (not shown)teeth156 are not engaged by any of thepawls157. InFIG. 15a,retractor120 is expanded by pivotingfirst portion122 in the direction of arrow R relative tosecond portion142 so thatlower pawl157 is biased into engagement withlower tooth137. InFIG. 15b,first portion122 is further pivoted in the direction of arrow R relative tosecond portion142 to expandretractor120 with theend156 ofmiddle pawl157 in engagement with themiddle tooth137. InFIG. 15cfirst portion122 is further pivoted in the direction of arrow R relative tosecond portion142 to expandretractor120 with theend156 ofupper pawl157 in engagement with theupper tooth137. It is contemplated thatteeth137 andpawls157 can be spaced so thatretractor120 is expanded incrementally. In one specific embodiment, the teeth136 andpawls157 are spaced so thatfirst portion122 is pivoted in 5 degree increments relative tosecond portion142, ranging from 0 degrees to 15 degrees. Other increments are also contemplated.
• FIGS. 16a-16billustrate anotherembodiment retractor320 that is similar toretractor20 but includes another proximal end configuration. InFIG. 16b,retractor320 is in its unexpanded configuration and inFIG. 16aretractor320 is in its expanded configuration.Retractor320 includes afirst portion322 having adistal end324, aproximal end326, and acollar328 atproximal end326.Retractor320 further includes asecond portion342 having adistal end344, aproximal end346, and acollar348 atproximal end346.First coupling member330aandsecond coupling member330bpivotally couplefirst portion322 tosecond portion342 about a pivotaxis A. Collars328,348 have a height that is less than the height ofcollars28,48 ofretractor20, reducing the retractor length. Viewing instruments and other instruments can be positioned in, over, and/or attached toretractor320 as discussed above with respect toretractor20.
• Collar328 includes afirst extension334aextending along one side thereof and abovecollar328, and asecond extensions334bextending along the other side thereof and abovecollar328.First extension334aandsecond extension334bare offset laterally with respect tocollar328 to form recesses for receiving respective ones of theextensions358a,358bofcollar348 therealong so thatextensions358a,358bdo not protrude into the working channel ofretractor320.Extensions358a,358bextend abovecollar348. Aligned holes are provided throughadjacent extensions334a,358aandadjacent extensions334b,358bto receivecoupling members330a,330b. Pivot axis A is thus offset proximally from the proximal ends ofcollars328,348 so thatfirst portion322 andsecond portion342 are expandable through their respective proximal ends tocoupling members330a,330b.
• Collar328 includes a first contact surface335abelow first extension358aofcollar348, and a second contact surface335bbelowsecond extension358bofcollar348.Collar348 includes a firstlateral extension356athat provides a contact surface belowfirst extension334aofcollar328, and an opposite second lateral extension that provides a contact surface belowsecond extension334bofcollar328. Withretractor320 in its unexpanded configuration as shown inFIG. 16b, a gap is formed between the adjacent extensions and engagement surfaces ofcollars328,348. Whenretractor320 is expanded sufficiently,extensions334a,334bengage respective ones of the contact surfaces ofcollar348, andextensions358a,358bengage respective ones of the contact surfaces ofcollar328, preventing over-expansion ofretractor320.
• While the invention has been illustrated and described in detail in the drawings and foregoing description, the same is to be considered as illustrative and not restrictive in character, it being understood that only the preferred embodiment has been shown and described and that all changes and modifications that come within the spirit of the invention are desired to be protected. For example, certain embodiments contemplate that the first and second portions of the retractor are not provided with proximal end collars. Other embodiments contemplate the first and second portions are not pivotally coupled to one another, but rather to intermediate members extending between the first and second portions along each side of the retractor.

Claims (22)

1-49. (canceled)

50. A kit for use in percutaneous surgery, comprising:

a retractor having a working channel extending between a proximal end and a distal end of said retractor, said retractor having a first portion coupled to a second portion, said first and second portions movable relative to one another to an expanded configuration; and

an expansion instrument positionable in said working channel and engageable with said first portion and said second portion to move said first and second portions to said expanded configuration, said expansion instrument mountable on said proximal end of said retractor.

51. The kit ofclaim 50, wherein said first portion is pivotally coupled to said second portion at said proximal end of said retractor and said first and second portions are pivotal from an unexpanded configuration to said expanded configuration.

52. The kit ofclaim 51, further comprising a first coupling member on one side of said retractor and a second coupling member on an opposite side of said retractor, said first and second coupling members pivotally coupling said first and second portions to one another.

53. The kit ofclaim 52, wherein said expansion instrument includes a pair of arms pivotally extending therefrom, said arms each including a mounting member engageable with a corresponding one of said first and second coupling members to mount said expansion instrument on said proximal end of said retractor.

54. The kit ofclaim 50, wherein said expansion instrument includes a pair of proximal handles pivotally coupled to one another and a pair of distal feet extending from a respective one of said pair of handles, each of said distal feet engageable with a respective one of said first and second portions.

55. The kit ofclaim 54, wherein at least one of said distal feet is adjustable to select a desired amount of expansion.

56. A kit for use in percutaneous surgery, comprising:

a retractor having a working channel extending between a proximal end and a distal end of said retractor, said retractor having a first portion coupled to a second portion, said first and second portions movable relative to one another for engagement in an expanded configuration; and

an expansion instrument positionable in said working channel and engageable with said first portion and said second portion to move said first and second portions to said expanded configuration, wherein with said working channel in said expanded configuration said expansion instrument is positionable in said working channel to disengage said first and second portions for movement to an unexpanded configuration.

57. The kit ofclaim 56, wherein said first portion is pivotally coupled to said second portion at said proximal end of said retractor and said first and second portions are pivotal between said unexpanded configuration and said expanded configuration.

58. The kit ofclaim 56, wherein said expansion instrument is mountable on a proximal end of said retractor.

59-77. (canceled)

78. The kit ofclaim 56, further comprising a series of tubular tissue dilators positionable one over the other to sequentially dilate bodily tissue, wherein said working channel of said retractor is sized for positioning about said tissue dilators when in an unexpanded configuration.

79. A kit for use in percutaneous surgery, comprising:

a retractor having a working channel extending between a proximal end and a distal end of said retractor, said retractor having a first portion coupled to a second portion in an unexpanded configuration, wherein said first and second portions are movable relative to one another for engagement in an expanded configuration to expand said working channel between said proximal and distal ends; and

a series of tubular tissue dilators positionable one over the other to sequentially dilate bodily tissue, wherein said working channel of said retractor is sized for positioning around said tissue dilators when said retractor is in said unexpanded configuration.

80. The kit ofclaim 79, further comprising an expansion instrument positionable in said working channel and engageable with said first portion and said second portion to move said first and second portions to said expanded configuration.

81. The kit ofclaim 79, wherein:

said first portion and said second portion each include opposite edges extending between a proximal end and a distal end thereof;

said second portion includes an engagement surface extending along at least a portion of each of said opposite edges thereof;

in said unexpanded configuration said edges of said first portion extend around said second portion; and

in said expanded configuration said opposite edges of said first portion engage adjacent ones of said engagement surfaces of said second portion.

82. The kit ofclaim 79, wherein said working channel has a generally circular cross-section in said unexpanded configuration and in said expanded configuration said working channel has a non-circular cross-section tapering from said distal end to said proximal end.

83. The kit ofclaim 79, wherein said first portion substantially envelopes said second portion in said unexpanded configuration.

84. The kit ofclaim 79, wherein said first portion is pivotally coupled to said second portion at proximal ends of said first and second portions and in said expanded configuration distal ends of said first and second portions are pivoted away from one another about said pivotally coupled proximal ends.

85. The kit ofclaim 79, wherein said first portion is pivotally coupled to said second portion along a pivot axis located proximally of proximal ends of said first portion and said second portion.

86. The kit ofclaim 79, wherein when in said expanded configuration:

said working channel tapers in size from said distal end to said proximal end; and

said second portion includes opposite edges extending between distal and proximal ends of said second portion that overlap adjacent edges of said first portion adjacent a distal end of said first portion.

87. The kit ofclaim 79, wherein said retractor forms a tubular body in said unexpanded configuration and said series of tissue dilators includes a series of elongated tubes of increasing diameter.

88. The kit ofclaim 79, wherein in both said expanded and said unexpanded configurations said first portion and said second portion enclose said working channel between said proximal and distal ends of said working channel.

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